Study Questions:

Among adult patients admitted to the intensive care unit (ICU), what is the risk of catheter-related bloodstream infection or symptomatic catheter-related deep vein thrombosis?

Methods:

3SITES (Venous Site for Central Catheterization) was a multicenter, randomized, controlled trial conducted in France. Eligible patients were those considered by the physician inserting the catheter to be suitable candidates for venous catheterization in at least two of the following three sites: the subclavian veins, the jugular veins, or the femoral veins. If all three venous access sites were considered suitable for catheter placement, the catheterization site was assigned in a 1:1:1 randomization scheme. If one of the three sites was not suitable on both the left and right sides of the body, the catheterization site was assigned in a 1:1 randomization scheme for the other two sites. The use of ultrasonographic guidance during catheter insertion was not randomized. After aspectic removal, the catheter tips were sent for quantitative culture. Within 2 days of removal of the catheter, compression ultrasonography was performed at the insertion site to confirm symptomatic catheter-related deep vein thrombosis. The primary outcome was the incidence of major catheter-related complications from the time of catheter insertion to 48 hours after catheter removal. Major complications were defined as the composite of catheter-related bloodstream infection and symptomatic deep vein thrombosis.

Results:

A total of 3,027 patients were included in the study. A total of 3,471 catheters (1,284 jugular, 1,171 femoral, and 1,016 subclavian) were included. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1,000 catheter-days; p = 0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio [HR], 3.5; 95% confidence interval [CI], 1.5-7.8; p = 0.003) and in the jugular group than in the subclavian group (HR, 2.1; 95% CI, 1.0-4.3; p = 0.04), whereas the risk in the femoral group was similar to the jugular group (HR, 1.3; 95% CI, 0.8-2.1; p = 0.30). The frequency of major mechanical complications in the three-choice comparison differed according to insertion-site group (p = 0.047), with 18 events in the subclavian group, 12 events in the jugular group, and 6 events in the femoral group. Pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian insertions and 4 (0.5%) of the jugular-vein insertions.

Conclusions:

Compared to jugular-vein or femoral-vein catheterization, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis, but a higher risk of pneumothorax.

Perspective:

This is a valuable study, which establishes that the risk of major complications differs according to the site of central venous catheterization in patients in the adult ICU. However, the authors note that the risk of grade 3 or higher complications was similar among the three insertion sites and that ‘an ideal site for central venous catheter insertion does not exist.’ If the expected duration of catheterization is expected to be significant, the cumulative reduction in risk of infectious and thrombotic complications (which increase with exposure) associated with subclavian-vein catheterization may offset the risk of pneumothorax with this site. Decisions about site selection should be individualized and account for anticipated duration of exposure.